Indiana on Tuesday became the latest state to expand its Medicaid program through the Affordable Care Act, as another Republican governor agreed to accept federal dollars to extend government health coverage to low-income state residents.
Starting Feb. 1, an estimated 350,000 uninsured, poor people in Indiana will be able to enroll in Medicaid, a long-held goal of healthcare leaders and patient advocates in the state who have bemoaned poor health outcomes there.
Indiana's move, which had been closely watched nationally, marks a significant victory for the Obama administration. It has been working to persuade Republican state leaders to back coverage expansions made possible through the 2010 health law often called Obamacare.
"The administration will continue to work with governors interested in expanding Medicaid to devise approaches that work for their states while keeping faith with the law's goals and consumer protections," Health and Human Services Secretary Sylvia Mathews Burwell said Tuesday after Indiana Gov. Mike Pence announced the expansion.
His announcement came after years of negotiations between the state and the federal government.
Thirteen states with GOP governors have now expanded Medicaid, including four that did so under previous Democratic administrations. Altogether, 28 states and the District of Columbia have broadened their Medicaid programs.
The Indiana expansion also makes the state a potential national model for other Republican state leaders who have demanded greater flexibility to redesign their Medicaid programs.
Indiana's expansion — which builds on a small state offering for low-income adults called the Healthy Indiana Program — includes several unusual features designed to encourage Medicaid patients to take greater responsibility for their healthcare.
To qualify for comprehensive Medicaid coverage, low-income Hoosiers will have to make small contributions to a special healthcare account, modeled on private health savings accounts that are becoming increasingly widespread in commercial insurance.
Failure to make these contributions can result in mandatory co-pays for some medical procedures. Program participants could also be subject to co-pays for use of the emergency room, a feature intended to encourage more economical use of medical resources.
Such emergency room co-pays, though common in commercial insurance, are still rare in government health insurance programs for the poor.
"We have worked hard to ensure that low-income Hoosiers have access to a healthcare plan that empowers them to take charge of their health and prepares them to move to private insurance as they improve their lives," Pence said Tuesday in Indianapolis.
The expansion also drew praise from advocates for low-income patients in the state.
"We are really happy that, starting today, we will be able to say that there is something available for everyone here," said Caitlin Priest, public policy director for Covering Kids and Families of Indiana.
The Obama administration historically has been leery of making low-income patients pay more for their medical care, which advocates caution could dissuade patients with few resources from seeking needed help.
But eager to win over GOP state leaders, federal officials have become increasingly open to these proposals. The administration previously granted permission for more limited cost-sharing plans in Iowa and Michigan, both of which also have Republican governors.
And administration officials are in talks with GOP health officials from Tennessee, Utah and other states that are seeking ways to expand their Medicaid programs through the federal health law.
But opposition to any coverage expansion through that law remains strong in conservative circles. Indiana's governor endured criticism from many right-wing commentators as he negotiated with the Obama administration.
And across the Deep South, Republican-elected officials in Texas, Louisiana and other states remain fiercely opposed to expanding Medicaid.